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medicina
Brief Report
Pneumomediastinum and Pneumothorax as RelevantComplications of Sub-Intensive Care of Patients with COVID-19:Description of a Case Series
Maria Gabriella Coppola 1,*, Marina Lugarà 1, Stefania Tamburrini 2 , Pasquale Madonna 1, Claudio Panico 3,Giuseppe Noschese 4 and Eduardo Pone 4
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Citation: Coppola, M.G.; Lugarà, M.;
Tamburrini, S.; Madonna, P.; Panico,
C.; Noschese, G.; Pone, E.
Pneumomediastinum and
Pneumothorax as Relevant
Complications of Sub-Intensive Care
of Patients with COVID-19:
Description of a Case Series. Medicina
2021, 57, 919. https://doi.org/
10.3390/medicina57090919
Academic Editor: Pierpaolo Di Micco
Received: 30 July 2021
Accepted: 28 August 2021
Published: 1 September 2021
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Attribution (CC BY) license (https://
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1 UOC Medicina Generale PO Ospedale del Mare ASL Napoli 1 Centro, 80147 Naples, Italy;[email protected] (M.L.); [email protected] (P.M.)
2 UOC Diagnostica per Immagini PO Ospedale del Mare ASL Napoli 1 Centro, 80147 Naples, Italy;[email protected]
3 UOC Chirurgia Toracica PO Ospedale del Mare ASL Napoli 1 Centro, 80147 Naples, Italy; [email protected] Sub Intensiva COVID PO Ospedale del Mare ASL Napoli 1 Centro, 80147 Naples, Italy;
[email protected] (G.N.); [email protected] (E.P.)* Correspondence: [email protected]
Abstract: Lung failure has been the most common cause of hospitalization for COVID-19. Yet,bilateral interstitial pneumonia has not been the only cause of lung failure of these inpatients, andfrequently they develop other illnesses associated with COVID-19. Pulmonary embolism has beenthe most looked for in the world, but rarely other pneumological diseases, such as pneumothoraxand pneumomediastinum, have been described and associated with a worsening prognosis. We herereport our clinical experience associated with the occurrence of pneumothorax and pneumomedi-astinum in a cohort of inpatients hospitalized in our division of medicine in a regular ward or in asub-intensive ward.
Keywords: pneumomediastinum; pneumothorax; non-invasive ventilation; COVID-19
1. Background
Pneumomediastinum and pneumothorax are rarely diagnosed in an emergencyroom [1,2]. Usually, spontaneous pneumomediastinum is more frequently describedin young patients with a history of asthma or recent inhalation of recreational drugs [2].Pneumothorax is classified as primary spontaneous pneumothorax in persons withoutclinically apparent lung disease-associated risk factors, including male sex, tall stature,smoking and a family history of pneumothorax or secondary spontaneous pneumothoraxas a complication of preexisting lung diseases, post-traumatic lung disease or iatrogeniclung disease [1].
Pneumomediastinum and pneumothorax causes include barotrauma in patients’asthma, COPD, pulmonary infections, bronchiectasis and more (e.g., lung cysts, lungmalignancy or iatrogenic injuries from endoscopy, surgery or central line placement) [3].
On the other hand, pneumomediastinum and pneumothorax have been reported asuncommon complications in pneumonia, caused by staphylococcus, interstitial pneumoni-tis and also including Pneumocystis carinii associated with human immunodeficiencyvirus (HIV) and/or tuberculosis [4].
During the pandemic caused by SARS CoV2, due to the complexity of the disease andtherapeutic approach, an increase of pneumomediastinum and pneumothorax have beenreported in the daily clinical management, although the epidemiology of this complicationis difficult to be understood due to multiple case reports, few cohorts are present in theliterature [5].
Medicina 2021, 57, 919. https://doi.org/10.3390/medicina57090919 https://www.mdpi.com/journal/medicina
Medicina 2021, 57, 919 2 of 6
From a clinical point of view, the occurrence of pneumomediastinum and pneumotho-rax may induce a severe clinical complication of all acute illnesses (e.g., COVID-19), whichmay increase the morbidity and mortality of patients.
We have reported a series of six patients with pneumothorax and pneumomediastinumassociated with COVID-19 in our cohort of patients.
2. Description of Cases
During the SARS-CoV-2 pandemic, in our sub-intensive area of the Medicine-COVID-19 unit, we observed six cases of pneumomediastinum and one case of pneumothorax as acomplication of the clinical scenario in patients with SARS-CoV-2 associated pneumonia.
Pneumomediastinum and pneumothorax are also reported as rare complications ofNIV, but the real frequency during other medical illnesses is still unknown. Patients thatwe found affected by pneumomediastinum, in fact, showed progressive lung failure andrequired therapeutic support with non-invasive ventilation (NIV). The most commoncomplications of NIV are infections by bacteria of the high respiratory tract, as far as for allpatients that require mechanical ventilation [6,7].
In our study, we reported the occurrence of pneumothorax and pneumomediastinumduring treatment in a sub-intensive area of our division of medicine for all patients affectedby lung failure for COVID-19. All patients were males with a mean age of 59.63 years. Froma clinical point of view, the younger patients presented with a small spontaneous pneumo-mediastinum and positivity to nasopharyngeal swab for SARS-CoV-2 while radiologicalfindings of interstitial pneumonia were rarely detected; his personal anamnesis did notreveal smoking or COPD or any type of trauma before hospitalization or recent treatmentwith NIV for SARS-COV 2 infection. This patient had not complained of any respiratorysymptoms. The small pneumomediastinum was only detected incidentally to the chestCT. Another patient with a history of bullous emphysema showed subcutaneous emphy-sema over the lower neck, spontaneous extensive right-sided tension pneumothorax, smallleft-sided pneumothorax and pneumomediastinum on chest-X-ray a few days after thepositive nasopharyngeal swab to SARS-CoV-2. He went to the emergency room of anotherhospital with a sudden breathlessness crisis, and he was treated with immediate drainagecatheter placement (Figures 1 and 2). He was subsequently transferred to our COVID-19 Unit.This latter patient had no other comorbidities, rarely took ICS/LABA/LAMA therapy athome and had no previous episodes of pneumothorax.
From a radiological point of view, five of the six patients showed extensive bilateralinterstitial pneumonia without associated pulmonary embolism, but three of them showedan overlapping gram-negative aerobic bacterial infection (e.g., Acinetobacter baumanii,Pseudomonas fluorescens or Corynebacterium striatum) requiring multiple rounds ofbroad-spectrum antibiotics.
The other clinical characteristics and comorbidities of observed patients are summa-rized in Table 1.
Four patients during the hospital course received non-invasive positive pressure ven-tilation (NIPPV) with a Pressure Support (PS) of 5–7 cmH2O and a positive end-expiratorypressure PEEP started at 10 cmH2, achieving an average tidal volume of about 450 mLof developed pneumomediastinum. After a good response to NIPPV therapy, PEEP wasreduced to 8 cmH2. Yet, patients presented a fluctuating clinical response to therapyand, after significant respiratory distress and a subsequent chest CT, demonstrated anextensive pneumomediastinum. Physical examination showed bilateral cervical subcuta-neous emphysema, spreading to both supraclavicular fossae, also confirmed by CT scan(Figure 3).
Medicina 2021, 57, 919 3 of 6Medicina 2021, 57, x FOR PEER REVIEW 3 of 6
Figure 1. Chest X-ray showing right-sided chest tube placed for pneumothorax and mediastinal emphysema in COVID-19 patient.
(a)
(b)
Figure 2. A typical case of a COVID-19 pneumothorax and pneumomediastinum patient (a) chest TC showing pneumothorax extended at 75% of the right lung and large mediastinal emphysema; (b) Coronal CT showing chest drainage for pneumothorax at right lung anteroposterior projection image.
Figure 1. Chest X-ray showing right-sided chest tube placed for pneumothorax and mediastinalemphysema in COVID-19 patient.
Medicina 2021, 57, x FOR PEER REVIEW 3 of 6
Figure 1. Chest X-ray showing right-sided chest tube placed for pneumothorax and mediastinal emphysema in COVID-19 patient.
(a)
(b)
Figure 2. A typical case of a COVID-19 pneumothorax and pneumomediastinum patient (a) chest TC showing pneumothorax extended at 75% of the right lung and large mediastinal emphysema; (b) Coronal CT showing chest drainage for pneumothorax at right lung anteroposterior projection image.
Figure 2. A typical case of a COVID-19 pneumothorax and pneumomediastinum patient (a) chestTC showing pneumothorax extended at 75% of the right lung and large mediastinal emphy-sema; (b) Coronal CT showing chest drainage for pneumothorax at right lung anteroposteriorprojection image.
Medicina 2021, 57, 919 4 of 6
Table 1. Clinical characteristics of observed patients with pneumomediastinum and pneumothorax.
Case 1 Case 2 Case 3 Case 4 Case 5 Case 6
Pneumomediastinum 1 1 1 1 1 1
Pneumothorax 0 0 0 0 0 1
Age 63 59 68 78 20 76
Smoking 0 0 0 1 0 0
Males 1 1 1 1 1 1
Diabetes 0 0 0 1 0 0
Coronary disease 0 0 0 1 0 0
Hypertension 0 0 1 1 0 0
COPD 0 0 0 0 0 1
NIPVV 1 1 1 1 0 0
Hospitalization length (days) 33 30 51 40 27 41
Overlapping bacterial pneumonia 0 0 1 1 0 1
Death for non-lung failure 0 0 0 0 0 0
Death for lung failure 0 0 0 1 0 0Medicina 2021, 57, x FOR PEER REVIEW 5 of 6
Figure 3. Coronal CT image shows multiple mixed ground-glass opacities in both lungs and pneumomediastinum.
The common CT manifestations of COVID-19 include bilateral ground-glass opacities (GGO), especially in peripheral, subpleural or posterior areas, with or without consolidations. Chest CT is a diagnostic test to identify and predict COVID-19 in patients with suspected symptoms because of its high sensitivity and high negative predictive value [12,13].
In the context of the COVID-19 infections, the pathogenesis of the pneumomediastinum and pneumothorax is due to alveolar rupture secondary to severe diffuse alveolar and vascular endothelium damage. Episodes of coughing that increase the pressure in the chest, positive pressure ventilation, prone position therapy and steroid therapy may contribute to the development of pneumomediastinum and pneumothorax [14].
Yet, because during pandemic the demand for NIV for patients in the emergency room has been increasing day by day, we suggest considering the risk of pneumothorax and pneumomediastinum in those patients that do not show improvements during NIV. Fast identification of severe clinical complications, such as pneumothorax and pneumomediastinum, is fundamental as far as those of superimposed bacterial infections and/or pulmonary embolism.
In our experience, the occurrence of pneumothorax and pneumomediastinum has been associated with prolonged hospitalization and worse outcomes when overall deaths or deaths due to lung failure are considered.
Although this is a short clinical series, a few reports are present in the Medline regarding pneumothorax and pneumomediastinum with large cohorts. Therefore, our data need to be confirmed on a larger population, but based on this experience, we suggest considering pneumomediastinum and pneumothorax as relevant complications, not only
Figure 3. Coronal CT image shows multiple mixed ground-glass opacities in both lungsand pneumomediastinum.
Medicina 2021, 57, 919 5 of 6
Regarding patients that received NIPPV, the average number of days between ven-tilation and subsequent barotrauma was 8.5 days. Four patients did not show personalanamnesis comorbidities associated with the increased risk of pneumomediastinum. Twoof them had a medical history significant for hypertension, Type 2 diabetes, and one ofthem also had ischemic heart disease.
We treated pneumomediastinum in a conservative way in all patients by monitor-ing via HRCT, where gradual improvement was observed. One of them, because of anunderlying ischemic heart disease, died with acute cardio-respiratory failure during hospi-talization. Only one patient showing extensive pneumothorax required drainage becauseof a worsening respiratory condition.
However, the occurrence of these kinds of complications also induced a prolongedaverage of hospitalization length (mean vs. 24, 28 days).
At our hospital, the incidence of pneumomediastinum/subcutaneous emphysema was5.45%, and the incidence of pneumothorax was 1.1%. Several clinical cases have been foundin the literature describing pneumomediastinum or pneumothorax, or both simultaneously,and related to barotrauma, as complications of COVID-19 infection [5,8–10]. One studyshowed that patients with COVID-19 infection and invasive mechanical ventilation (IMV)had a higher rate of barotrauma (10% pneumomediastinum and 9% unilateral or bilateralpneumothorax) than patients with acute respiratory distress syndrome and patients withoutCOVID-19 infection [11]. The occurrence of pneumomediastinum and pneumothoraxincreases in acute medical illnesses as lung failure with a combination of parenchymalinjury, as we observed in patients with COVID-19, and severe systemic inflammation isalso associated with therapeutic supports with additional positive pressure ventilation asIMV and NIV. Underling comorbidities as COPD may also further increase the risk of theseclinical complications.
The common CT manifestations of COVID-19 include bilateral ground-glass opacities(GGO), especially in peripheral, subpleural or posterior areas, with or without consol-idations. Chest CT is a diagnostic test to identify and predict COVID-19 in patientswith suspected symptoms because of its high sensitivity and high negative predictivevalue [12,13].
In the context of the COVID-19 infections, the pathogenesis of the pneumomedi-astinum and pneumothorax is due to alveolar rupture secondary to severe diffuse alveolarand vascular endothelium damage. Episodes of coughing that increase the pressure inthe chest, positive pressure ventilation, prone position therapy and steroid therapy maycontribute to the development of pneumomediastinum and pneumothorax [14].
Yet, because during pandemic the demand for NIV for patients in the emergencyroom has been increasing day by day, we suggest considering the risk of pneumothoraxand pneumomediastinum in those patients that do not show improvements during NIV.Fast identification of severe clinical complications, such as pneumothorax and pneumo-mediastinum, is fundamental as far as those of superimposed bacterial infections and/orpulmonary embolism.
In our experience, the occurrence of pneumothorax and pneumomediastinum hasbeen associated with prolonged hospitalization and worse outcomes when overall deathsor deaths due to lung failure are considered.
Although this is a short clinical series, a few reports are present in the Medlineregarding pneumothorax and pneumomediastinum with large cohorts. Therefore, our dataneed to be confirmed on a larger population, but based on this experience, we suggestconsidering pneumomediastinum and pneumothorax as relevant complications, not onlyin frail patients that have comorbidities as COPD but also to those that receive NIV supportwithout fast clinical improvements.
Author Contributions: Conceptualization and methodology: all authors; Investigation and datacuration: M.G.C., M.L.; Writing—original draft preparation: M.G.C.; Writing—review and editing;M.G.C., M.L.; Visualization: all authors. All authors have read and agreed to the published versionof the manuscript.
Medicina 2021, 57, 919 6 of 6
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted according to the guidelines of theDeclaration of Helsinki and approved by the “Campania Centro” Ethics Committee, Naples, 80147,Italy (Prot. N. 399/C.E. 23-2020 OSS).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Data is contained within the article.
Conflicts of Interest: The authors declare no conflict of interest.
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